Tuesday, February 26, 2008

This month's Nutrition Action Health Letter from the Center for Science in the Public Interest has an article about caffeine -- "The Good, the Bad, and the Maybe". They describe one study on how caffeine affects driver alertness as follows:

French researchers accompanied young males as they drove 125 miles on a highway between 2 a.m. and 3 a.m. When the young men were given coffee with 200 mg of caffeine before getting behind the wheel, they inadvertently crossed into another lane an average of two times during their drive. When they were given decaf, they crossed over an average of six times.

I'm guessing that there was no IRB review of this study protocol.......

Monday, February 25, 2008

We are proud to be chosen by Beth Israel Deaconness Medical Center to provide project management and practice consulting services to their EHR deployment project. We're working closely with BIDMC's excellent staff and with eClinicalWorks and Concordant, who were also chosen for the project and who we know very well from the MAeHC project.

This is the first commercial project undertaken by MAeHC. As we near the end of our seed funding from Blue Cross Blue Shield of Massachusetts, we are pursuing a 'public service' strategy and a 'commercial' strategy. The public service strategy is to get collaboratively provided resources to build on the successess and lessons of the pilot projects and launch Phase 1 of a statewide rollout. The 'commercial' strategy is to pursue paying customers inside and outside of the Commonwealth who have needs that we have the skills and interest to address. These strategies are complementary -- the lessons we learn from clinical leaders such as BIDMC will make us even more seasoned for the challenges of a statewide rollout. In return, if we can get any organization to avoid our mistakes and replicate our successes, our mission will be forwarded.

Wednesday, February 20, 2008

There was a Dutch study published last week showing that providing better quality care, in this case to smokers and obese patients, raises the cost of health care because it prolongs the lives of patients (here's the Boston Globe article and here's the actual study). Prolonging lives means they need care for longer periods of time and they die of diseases that are more expensive to treat -- unlike lung cancer, for example, for which there is no treatment, which makes it a relatively cost-effective way to die; better still, using this calculus, would be getting hit by a Mack truck. But I digress....

Anyway, the study has been actively blogged on the WSJ health blog already, but one angle I haven't seen discussed is the impact of this on health insurance dynamics. A not uncommon refrain among commercial health insurers is that their investments in quality improvement are reaped mostly by Medicare, because the benefits of healthier enrollees don't really pay off until those enrollees are older and mostly off commercial insurance. The Dutch study suggests that for certain conditions the opposite is true -- higher quality care may increase costs to Medicare (and Social Security) by increasing the fraction of people who live to draw on Medicare (and Social Security) benefits.

States like Pennsylvania and Vermont have adopted the chronic care model as state policy, not only to promote better quality lives for their citizens, but also on the assumption that there are cost savings down the road. The National Quality Measures Clearinghouse has literally thousands of quality measures, and the drumbeat of quality improvement is beating louder and louder every day. Yet, the Dutch study and work by the Partnership for Prevention suggest that the economics for universally applied quality improvement just aren't there.

A real moral dilemma for our society could come with the realization that the Dutch findings may be more generally true -- it may actually cost more to get higher quality care. David Cutler has argued that we should spend more on health care because the marginal returns are so high, and measured in lives saved and pain avoided, that is certainly true. But we live in a reimbursement system where costs are vigorously monetized but benefits aren't, and literally no one has an incentive to put in more money for anything. Funding longer lives and less pain for all will be much easier said than done.

Monday, February 18, 2008

When I was younger, I took an immersion Russian course at Norwich University in Vermont. On the first day, our teacher, who was himself a gifted, fluent non-native Russian speaker, asked each of us why we wanted to learn Russian. One of the students said "I've always dreamed of reading War and Peace in the original." The teacher responded in a joking tone that revealed the hard truth: "Yes, and I too hope to be able to do that someday." We all realized in that moment that we had a hard slog ahead.

I was reminded of that moment when I read an article in this week's Economist magazine about the UK National Health Services's much troubled "Choose and Book" system (see Notional Health Server). The goal of the system is to "allow patients in the National Health Service (NHS), advised by their doctors, to choose the treatment they want, and book an appointment when they want it." Unfortunately, after 3 years of hard work, it still hasn't worked out that way. Over 50% of physicians have a negative view of the system according to the British Medical Association. One of the physicians interviewed said that in her experience the system is so slow that it takes about 2 minutes for each visit request, and even then, it functions properly only 10% of the time.

Those familiar with health IT will immediately recognize how ambitious Choose & Book goals are and, I suspect, feel sympathy for their plight. As the article put it, the system will only perform as designed if everything goes right, meaning that the hospital, physician, and health trust systems that it needs to interact with fit together perfectly, and that the physicians and administrators who use those systems fit together perfectly as well. You would think that this could be accomplished in a government-owned health system...........and you'd be wrong. Which leaves those of us living in a highly decentralized system wondering just how ambitious we should be.

Unfortunately, users, and especially physician users, assume that they'll immediately be able to do the kinds of things that Choose & Book is supposed to, and it's often hard to ratchet expectations back to reality. In the MAeHC pilot projects, we're launching health information exchanges in three pilot communities and we're constantly in the struggle of trying to prevent the perfect from being the enemy of the good by reminding physicians that the first version is "Version 1.0" which will be improved over time. It's fantastic that our users are engaged and they want to get value out of the system; it won't be fantastic if "Version 1.0" isn't good enough to want them to stick around for Versions 2, 3, and 4.

I find managing this tension -- between designing the perfect architecture vs launching something good and attainable -- to be one of the biggest challenges in the health IT space. The most difficult part of the challenge is that the culprit isn't the technology, it's the lack of alignment of the technology and processes used by the most important data sources, hospitals and physician offices. It's the same problem faced by Dossia and Microsoft's Health Vault and Google Health -- will our users be willing to wait for the system to catch up with the technology?

Wednesday, February 13, 2008

In the constant battle to control health care costs, there has been lots of experimentation with controlling the supply-side (eg, certificates of need, cutting back reimbursement levels to providers, etc) and the demand-side (eg, coverage limits, tiering, co-pays, co-insurance, etc). Health care costs continue to rise rapidly, but that doesn't mean that these methods have failed -- we don't know what cost growth would have been like without them.

There's been a lot of emphasis recently on digging further into the nature of demand -- rather than just cutting back patient choice, why not cut back on patient need by getting patients to be healthier in the first place. Employers pressure health insurers to curb cost growth, but the insurers argue that employers don't do enough to get employees to be healthy in the first place. Physicians and hospitals, pressured to improve quality and efficiency, complain that patient adherance is a large barrier to improved care -- if patients don't take simple measures to be healthy, and/or refuse to follow prescribed treatments, what is a provider to do?

This seems like a win-win-win; people shouldn't need that much encouragement to become healthier, and the results will be beneficial to all. Well, a large employer that is also a very savvy health care business has been experimenting with direct patient incentives to encourage healthier lifestyles, and they're finding that it's not quite as easy as it sounds (see Employers experiment with tough get-healthy regimes).

Clarian Health Partners of Indianapolis is an integrated delivery network that employees 13,000 people. They tried to segment their employee risk pool by setting higher premiums for employees who don't attempt to improve their health in certain ways, such as smoking, obesity, and high cholestorol. We as a society already allow this type of risk segmentation in other areas of insurance, and indeed, it's the very basis of preventing moral hazard incentives that undermine the efficiency gains of insurance to begin with! For example, bad drivers, and those assumed to be bad drivers (like teenagers), pay a lot more for insurance. Seems like a slam dunk, right?

Clarian ran into a buzz-saw and never rolled out the program. Some critics saw it as an intrusion of privacy -- an employer shouldn't be allowed to dictate what employees do outside of work. Others saw it as discrimination -- an employer shouldn't be able to single out certain groups of people based on health history or habits.

One bizarre quote in the article points out how weird this conversation can get. Commenting on why his company doesn't raise premiums for overweight employees, an auto-parts supplier stated that:

"We're a little bit reluctant to go down that path. It's not really the fear of litigation as much as the lack of evidence that it works," he said. "I look at my own reaction and if I were going to be penalized for my weight I'd say, 'If for an extra $15 a month I can strap the feed bag on I'm going to do that and I'm going to make sure I get my money's worth.'"

I can't think of a better summary of the depth of the problems that we face.

I've heard anecdotally that health plans are retrenching on so-called pay-for-performance (P4P) reiumbursement programs because they're not getting the return that they hoped to get. There seems to be some evidence of this in the data as well -- projections from 18 months ago suggested gushing growth (see The state of P4P programs), but the trend more recently seems to be on refinement rather than expansion (see It's everywhere but measuring effectiveness of P4P is challenging). There seems to be a trend out there away from pure P4P and toward mixed reimbursement models that blend in capitation with performance-based payment, exemplified by two new approaches.

The best description I've seen of the benefits of moving back toward some type of capitation model is in Benjamin Brewer's column in yesterday's Wall Street Journal (Finding a Medical Home May Be Just What the Doctor Ordered). Dr. Brewer gives an excellent ground-level view of what it means to pay physicians to manage patients instead of acute episodes, and why such an approach might really offer benefits to patients and physicians alike.

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About the Massachusetts eHealth Collaborative

MAeHC is a non-profit organization which develops and implements community-based strategies for adoption of electronic health records and health information exchange. We work with communities in Massachusetts and all across the country. We are proud to be backed by 34 leading non-profit Massachusetts organizations who share a common goal of facilitating widespread adoption of health IT to promote higher quality, safety, efficiency, and affordability of health care.